FORM 1: HEALTH CENTER WORK PLAN FOR REACHING EVERY PUROK EVERY QUARTER

Name of RHU/BHS: ________________________________ Date of Completion: _____________________

Name of Midwife: _______________________ Name of BHW: __________________________

QUARTER ___ QUARTER ____

Result of previous Dates for catch up Results of Dates for catch up

Barangay Purok card checks Date for Date for next latest card Date for Date for next Results of latest
Name Name (HR/LR/ND*) master door to door master door to door card check (HR,LR,
listing __ __ __ card check check (HR,LR, listing __ __ __ card check ND)
(month) (month) (month)
ND) (month) (month) (month)
Form 2: MASTERLIST OF CHILDREN (0-59 MONTHS OLD)

Name of RHU/BHS: ____________________________________________ Name of Midwife: _____________________________

Name of Barangay: _____________________________________________ Name of BHW: ________________________________
Name of Purok: ________________________________________________ Date of Completion: ____________________________

Card check Immunization

(12- Status (12-23m) Place date if vaccine has been given (mm/dd/yyyy) Place √ if mother recall TT
23m) Place doses
Name of Child Birthday
Detailed Place √
Name of address in √
No. (lastname, first name, Age (mm/dd/ Purok Remarks
Mother

HepB BD
(months)

Penta 2

Penta 3
including

Penta 1
mi) yyyy)

OPV 1

OPV 2

OPV 3

MCV1

MCV2
PCV1

PCV2

PCV3
with w/o Incomplete

BCG
landmarks

TT1

TT2

TT3

TT4

TT5
IPV
Complete (partial, zero
card card or no card)

10

11

12

13

*completely immunized: 12-23 month old with 3 Penta doses, 3 OPV doses, 1 anti-measles and 1 MMR
Form 4: QUARTERLY CARD CHECK IN HIGH RISK PUROK TO MEASURE RISK STATUS IN ONE PUROK
Method: DOOR TO DOOR VISITS FOR CHILDREN AGED 12 TO 23 MONTHS
BHS Name: ____________________ Barangay Name: _________________________ Date: __________
Purok Name: _______________________ Health Worker Name: _______________________

Immunity Gap Card Check (12 to 23 months)

No. of Children
No. of
Completely No. with zero with No Card
No. of Partially
Immunized dose (Write name
Door Immunized of child with zero
No. No. of Children No. of dose and no card
aged between children with (3 doses of on the back of
12-23 months card (Any one dose of
Penta & OPV (Card shows no this form and
plus MCV1 and Penta, OPV, or doses received) check in TCL)
MCV missed)
MCV2)

10

11

12

13

14

15

16

17

18

19

20
FORM 5: CONSOLIDATED MONITORING OF QUARTERLY CARD CHECKING IN HIGH RISK PUROKS

Health Center Name: _________________________ Barangay Name: ______________________________ Date: ______________

Results of Card Checks Result of Catch UP

Date of No. %
Name of High Risk Card No. of No. of No. of No. of % Decision on Decision on Date Catch
Purok with no. with Children Up Done for No. Penta No. MCV
Check Children Children Completely Partially zero No Card Completely High or without High or High Risk Dose Given Given
Checked with Card Immunized Immunized Immunized Low Risk Low Risk
dose Cards Purok

% of Completely Immunized - In puroks where most children have cards:  Children without cards - In puroks where a significant number of children do not have cards:
Number of children with complete immunization X 100 Number of children without cards X 100
Total number of children with cards Total number of children checked
High Risk Purok: <90% of children had complete immunization   High Risk Purok: ≥80% of children aged 12 to 23 months are without cards
FORM 6: QUARTERLY SUPERVISORY CHECKLIST

Name of Health Center: ________________________

Name of Supervisor: ___________________________ Date: _________________

Component What to check What to look for Enter YES or NO Comment

·        TCL updated and complete
Check TCL ·        TCL showing unimmunized gaps
SERVICE DELIVERY

·        Lists of names for follow up doses

Map ·        HC maps showing barangays and puroks
·        Barangays listed with population of each
Lists of population ·        Names of puroks listed
·        High Risk Puroks identified
Session Plan ·        Outreach sessions planned and
monitored
·        Chart up to date
Monitoring Chart
·        Magnitude of drop outs displayed
MONITORING

·        Quarterly card checking planned and

Card Checking in HR monitored
puroks
·        Results of card check documented
·        Coverage by Barangay recorded
Low performing
Barangays ·        Low performers investigated by review of
TCL
COLD CHAIN, LOGISTICS AND SURVEILLA

Reports of ·        Suspected cases reported and

NCE

suspected VPDs investigated on time

Case Investigation ·        Case investigation forms available in HC

Check Refrigerator ·        Ref. functioning, if not has report been

made and follow up
Temperature
monitoring ·        Temperature record twice per day
SUPPLY

Check vaccine ·        Vaccine log book in use

supply ·        Any stock out/over stock
·        Any expired vaccines discarded last &
Expired vaccines current year (if yes: write the name of vaccine
and quantity)
Immunization
AEFI

Safety ·        Any prefilling or re-capping of syringes

Poster with
national schedule ·        Immunization Schedule Poster displayed
COMMUNICATION

Mothers knowledge ·        Mothers correctly informed about next

dose/visit
Names and phone ·        Directory of BHWs names and phone
numbers of BHWs numbers
Session plan ·        Fixed and outreach sessions schedule
displayed displayed for public

Microplan available ·        Microplan shows activities for high risk

PLANNING AND
SUPERVISION

puroks
Supervisory plan ·        Schedule of supervisory visits
Supervisory log
book ·        Action taken from previous visits
 FORM 7: MANAGING AND MONITORING VACCINE SUPPLY

Name of Health Cneter: ________________________________ Name of Monitor: __________________________ Date completed: ________________

Item Record the following using the Vaccine Calculate the number of months of
Stock Card available stock.
Write the actual number and other information indicated of
Eligible Pop (EP): Total Population If expiry date is not available in the stock the vaccines available in the health facility Divide total vials counted by the calculated
x 2.7% register, then write “ NA” in the relevant monthly or quarterly needs.
column Recommenda
Monthly Needs
tions
Overstock (OS),
Total vials Expiry Date Total Vials Expiry Dates Status of VVM Total No. of Months Understock (US),
(1,2,3,4) Stockout (SO),
Optimum (O)

BCG (20-dose per vial)

(EP x 1 dose x 2.5/20/12 )
HEP B (10-dose/vial)
(EP x 1 dose x 1.1/10/12 )
PENTA (1-dose/vial)
(EP x 3 doses x 1.1/12 )
OPV (20-dose/vial)
(EP x 3 doses x 1.67 /20/12)
MEASLES (10-dose/vial)
(EP x 1 dose x 2/10/12)
MMR (5-dose per vial)
(EP x 1 dose x 1.1/5/12 )
PCV (1-dose/vial)
(EP x 3 doses x 1.1/1/12 )
ROTAVIRUS (1-dose/vial)
(EP x 2 doses x 1.1/1/12 )
TT (20-dose/vial)
(EP x 2 doses x 1.67 /20/12)
IPV (10-dose/vial)
(EP x 1 dose x 1.25 /10/12)
FORM 8: QUARTERLY RHU/ HC COVERAGE MONITORING

Name of RHU/HC: ___________________ Quarter Monitored: 1stQ ( ) 2ndQ ( ) 3rdQ ( ) 4thQ ( ) Name of Monitor: _______________ Date: __________

Un-immunized
Target Pop. Immunization Coverage (%) Drop-out Rates (%) Identify Problems
(No.)
Total Pop. ( < 1 year No. of Doses of Vaccines Administered No. of Priority
Barangay Name /4) Measles (D- (D- Good=if H is Good= if P is
(D/C*100) (E/C*100) (F/C*100) (G/C*100) C-E C-F Area
Cases E)/D*100 F)/D*100 95% above between -5 to 10
PENTA1- PENTA1-
No. No. PENTA1 PENTA3 MCV1 MCV2 PENTA1 PENTA3 MCV1 MCV2 PENTA3 MCV1 PENTA3 MCV1
Access Utili-zation

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